A Nutritionist Weighs in on Dropping Pounds with Jodi Bjurman

Dr. Furnas (00:02):
We've been hearing and seeing the results of those wonder drugs that help overweight America look and feel better. But why do some complain these drugs don't have much of an effect? And what do we do in the longterm? Welcome to Skintuition. I'm Heather Furnas.

Dr. Korman (00:21):
And I'm Josh Korman. As two plastic surgeons, we lay aside our scalpels and explore the nonsurgical world to bring you what's new, what's safe, and what to look for when you're ready to hit refresh.

Dr. Furnas (00:35):
It's a true pleasure to introduce Jodi Bjurman. Jodi has over 35 years of experience as a registered dietician and a certified diabetes educator. She works at El Camino Health in the Bay Area where she's developed nutrition related corporate employee training programs. Welcome, Jodi.

Jodi Bjurman (00:59):
Hello. Good morning. Glad to be here.

Dr. Korman (01:02):
So Jodi, between pills, injectable weight loss drugs and surgery options in an overweight America, you must have your hands full.

Jodi Bjurman (01:11):
Yes, I do get constant referrals for weight management, for pre-diabetes, for type two and some type one diabetics. So I don't think there will ever be a shortage of possible clients.

Dr. Furnas (01:28):
So before we get to those skinny shots, the Ozempic and Wegovy and Mounjaro, let's unpack all of these. What exactly has been the role of a registered dietician when you started in the profession and how has it changed?

Jodi Bjurman (01:46):
Well, registered dieticians have always been considered the nutrition experts because of the education that we're required to have prior to becoming registers. Maybe in the long distant path, dieticians were just sort of bean counters, that kind of a thing. But there are so many opportunities for those interested in this profession to go one of two routes. You can either become active in food service management of some sort or more on the clinical side of the profession doing the counseling or the nutrition assessment.

Dr. Korman (02:26):
So why do so many of my patients think they eat well, but they can't lose the extra weight and they're frustrated because they feel there's nothing more they can do?

Jodi Bjurman (02:37):
Well, there can be a lot of reasons that weight loss becomes more difficult. Sometimes when people are sensing that they're eating well, it could be a matter of them just not eating enough. They cut too much out in order to try to promote weight loss. There could be things that they're not considering, like alcohol for example, or the calorie density of foods. Maybe they're using more oils when they're preparing food, that sort of thing.

Dr. Korman (03:05):
So alcohol, can you focus on that a little bit? If you have a drink of wine, how many calories is in a glass of wine?

Jodi Bjurman (03:15):
Yeah, that's about a hundred, for a six ounce glass of wine. Beer would be closer to 150 for a 12 ounce beer. So usually the alcohol equivalent, 12 ounce beer, six ounce glass of wine or one and a half ounce shot of liquor would be similar, somewhere around a hundred to 150 calories. You have to think about though, that when people are drinking mixed drinks, there's often calories involved in whatever they're mixing that alcohol with.

Dr. Furnas (03:46):
It doesn't just taste good with nothing.

Jodi Bjurman (03:50):
There you go.

Dr. Furnas (03:53):
As far as the perception of eating, do you find that sometimes people think that they're not eating very much and they actually are, whether it's with snacks or, interestingly, I'm going to sort of also ask, you mentioned not eating enough and so could you kind of tackle both of those? I'm trying to get 30 pounds off, I think I'm eating well and right. How do you sort of break that down?

Jodi Bjurman (04:25):
When someone comes into my office and they have complaints similar to that, I have to start with figuring out what their expected calorie burn would be. So there is a well-researched equation that we use called the Mifflin St. Jeor equation, which calculates someone's resting energy burn. The factors are their lean body mass, their lean body weight, their height, their age, male versus female. There's a little separate calculation for that. And so I always compare that to what someone is bringing to me for, as a food diary. They will ask everyone who comes in to try to prepare three days of detailed journaling of what they've had to eat. I don't always get that. If they come in without it, then I have to ask them what's typical. And my job is to compare the calculated needs to what they are showing me. So if someone is not eating enough, what that typically means would be someone who is not even eating their resting calorie calculated calorie needs because that would typically, if someone is ingesting food below that level, that gradually will slow their metabolic rate down over maybe a couple of months. So in the endpoint, they're only burning their resting needs. They're not burning the amount that would be added for normal daily activities, which is about 30% higher.

Dr. Korman (06:01):
So if we're talking on the other end of the spectrum, this world of what are expensive calories, I don't know, I've heard many times that there's expensive calories and less expensive calories. Like fast food are less expensive calories, that's why it's in fast food, and high quality protein is actually quite a bit more expensive. Can you help us understand about quality of calories? Is a calorie, calorie calorie or is there really is differences?

Jodi Bjurman (06:34):
I would say in speaking of food energy, it is what it is. A calorie is a calorie. However, how long and how satisfied it makes us feel has a lot of variance. So if someone is eating foods that are more slowly digested, like higher fiber foods or maybe they have richer foods in their diet, they will feel satiated for longer. If they're eating more sugars and refined carbohydrates, generally that's going to be processed more quickly through the system and it might spike some appetite signals for people. But everybody is different and everyone has some need higher carbohydrate to feel comfortable, some need more protein. So there's a lot of body chemistry that goes into that. Part of the interview process is to figure out what's best for each person.

Dr. Furnas (07:33):
So it's not just this is a good menu for everybody. They should all have avocado in the morning with steel cut oats, and then for lunch have something. So there, how do you adjust for that?

Jodi Bjurman (07:49):
Well, I have to ask the right questions I suppose. So one of the questions would be what time do they get up in the morning? What time do they go to bed at night? So we see the framework of their active or just of their awake time and when do they feel, what are the timings of their meals? Because the stomach will usually empty within four to six hours. And if people are going longer than that between meals, they probably will be more likely to overeat once they finally get to food because their hunger levels are so high. If someone is like me, I'm kind of a fast processor of food, so it seems like I need to have something every two to three hours because that's when my energy levels start to call for some more assistance. So again, it's asking the right questions.

Dr. Korman (08:42):
So speaking of the three hours for I don't know how many years, I've always asked people, okay, what time do you go to sleep at night? And then I say, you really shouldn't be eating anything to eat or drink except for water for the three hours before you go to bed because the food gets converted to fat while you sleep. Is that actually true?

Jodi Bjurman (09:02):
I would say it needs a little bit of tweaking. So I would suggest if somebody is having issues with reflux, let's say you definitely want them to have at least two hours or so after their last meal before they go flat. So that's one thing that gives a parameter of how much time before sleep and are they waking up hungry in the middle of the night? Maybe they've gone too long without food. But I think for timing it's nice to have the cutoff time of food compared to the breakfast time, maybe at least 10 hours or more, ideally maybe 12. So they have that intermittent fasting sort of window to process nutrients during the night.

Dr. Furnas (09:49):
Now where the fat is on the body impacts your health and specifically fat around your intestines and where your liver and everything lives. We call this visceral fat because of viscera or basically the guts. So what options are there for people with a lot of visceral fat? And you can kind of tell, I'll explain to patients with a bulging abdomen when it's really very hard. There's not a lot of soft pinchable fat on the outside that fat is causing the belly to bulge because it's stuffed in below the muscles. So that's why it feels so hard and it can get worse as we pile years on and it's associated with bad diseases like heart attacks and things like that. And a lot of women will tell me since menopause, this is what happened. So what can be done? I think a lot of people say it's really hard to lose that weight.

Jodi Bjurman (10:55):
Well, so the visceral fat, typically the fat that's in the liver and around the organs that when you do calorie restriction for weight loss, the body wants to get rid of that. So that should be the first fat to go. But after menopause with the hormonal changes, our body fat in the women is going to relocate. We're not so much about the hips and the thighs anymore, we're more depositing fat around the center of the body similar to the male fat pattern. So if somebody's got a lot of internal visceral fat and external fat, it's all going to, if it's a female and they're menopausal, postmenopausal, it's going to be around the center of the body.

Dr. Korman (11:39):
What do you think about the role of hormones in weight management? Because so often after menopause and there's andropause in men, just like there is menopause in women, but so often people complain that they put on weight a lot as they get older, and hormones certainly have a role in that. But what do you think about the role of hormones in weight management, whether pill form patches and injections and basically how do you feel about hormones as supplements?

Jodi Bjurman (12:13):
First of all, dieticians are not one, we can't prescribe anything. That's the first thing. But there are certain nutrients that can help the body to produce hormones. So things like magnesium and zinc, perhaps vitamin D, these kind of things should be considered if there are hormonal imbalances. But we can't often do a whole lot nutritionally other than promote a well-balanced, well-rounded diet to support the body's own natural processes to do what it needs with the hormones. After that, it's up to the physicians.

Dr. Furnas (12:59):
So how do you evaluate a patient?

Jodi Bjurman (13:03):
It's actually one of my favorite parts of my work. I have people, when people come in, hopefully they've done a food diary, they sit down with me at the table that you see right behind here and I begin the interview process. And of course there's some objective information that I ask for. First height, we take the weight, know their ages and all of that. I ask about the digestive process. Do they have any chewing or swallowing issues? Do they have any reflux, any nausea? Are they having regular bowel movements? And if those are all good, we move past that into really exploring the timing of their day, their meals, and what would be the most typical two or three types of meals they would have say for breakfast, lunch, dinner and snacks. And then once I gather all that information, that usually takes up a good hour. And then after that I sit down and try to do all of the matchup between, okay, how much is this person eating? What are their calculated needs? What would the plan be? So patients in that very first visit, they may not walk out with a structured plan. They may walk out with basics like here's the general guidelines for lowering LDL, cholesterol from our nutrition care manual, some of the basic parameters of whatever the goals are that we're working on. And then after that we would work more specifically with the diet.

Dr. Furnas (14:33):
You mentioned a food diary and it seems that just the fact that you've got to have some accountability. Well, today, normally I would have six donuts, but because I am keeping this food diary, maybe I'll have a peanut butter and jelly sandwich instead.

Dr. Korman (14:53):
Five donuts. Five donuts.

Dr. Furnas (14:56):
Yeah, cut it down to five. Yeah, that won't be embarrassing. So just that may alter what they actually are eating, but it can also, I mean, do you use food diaries as a tool?

Jodi Bjurman (15:13):
They're definitely a tool and you hit on something that is very much a part of what keeps people coming back rather than a negative is because, so I typically work for somebody under one referral for a six month period of time. So they have this timeframe that they can use while they're making their adjustments in their diet. But people tell me that it's just nice to have somebody to come into that provides some accountability and we keep it light in here. I don't beat people over the head if they're not doing the right thing, but we spend time exploring. So why is it difficult for you to eat some of these foods that we know would be better for you? What is it about whole grains that you don't like or I have measuring tools on my table. I have cups, like a bowl for my kitchen. I have measuring cups, measuring spoons, and I say, how much oil do you throw into your pot when you, your skillet when you're cooking something? And so over time we just make these little shifts and that's the way to make behavior change more acceptable and something that can become part of an eating habit that will stay.

Dr. Korman (16:39):
So speaking of from the evaluation process, we often hear or feel that watching one's weight is a matter of self-discipline, but there are other factors that in fact impact all this like environment availability of healthy food and having a sedentary versus a physical job. How do you help people navigate those outside factors, things that they may or may not be able to affect, but those that ostensibly they will be able to. How do you do that?

Jodi Bjurman (17:13):
Well, it goes back to asking the right questions again. What are the barriers to change? If it's food availability, let's say there's somebody that comes into my office that is not the person who does the grocery shopping or the cooking, which are two main questions that I ask at the first interview is who's doing that? We might have to have a conversation about would you be willing to go along and ask for these things to be added to the shopping list? What are some options that you might consider to move your diet in a more healthy direction? There is a scenario that comes up from time to time when there's, let's say a woman who has three school-aged children in the house and they need or ask for certain foods that the mom should not be eating herself. They might have very high energy levels and sport demands and be just fine with having ice cream every night, but then mom is left with that temptation.

(18:20):
So I think managing do what you can with within your budget to bring the healthiest foods in the house. If ice cream is a thing, maybe consider a lower fat ice cream or maybe a frozen yogurt or something just to reduce the calories of it, but then work with the environment in the kitchen so that the best choices are available. I would caution the parents not to always give in to whatever the children are asking for because what they are exposed to in their diet, in their youth will probably likely become their dietary pattern when they're older as well. And so as parents, we are kind of the gatekeepers to getting our children used to the textures of the whole foods versus the sugary refined or more refined foods. So that's really important I think.

Dr. Furnas (19:15):
So you develop nutrition related corporate employee training programs. What do you teach in these training programs and why do corporations hire you in the first place? Do your lessons lower healthcare costs or increase employee productivity?

Jodi Bjurman (19:35):
Okay, so just to clarify, they don't hire me directly. They contract with an employee assistance program as part of their benefits within the company and under that umbrella of the employee assistance program, they are provided with certain hours of employee trainings from all different kinds of topics. One of the topics is nutrition. And for that, there are two seminars that are on the list currently that I go out and provide as needed. Well, I don't go out anymore. Basically they're all on Zoom, but so there's one called Life in the Fast Lane, a Survival Guide to Healthy Eating. And that's a really fun seminar because it kind of starts out with teaching the basics of good nutrition and what we need. But then it also talks about the importance of planning ahead and what are some meals that are easy and quick to make and getting the shopping list together and understanding food labels and then also maintaining healthy choices when you do eat out during the week.

(20:48):
So that's kind of the nutrition survival guide seminar. And then the other one is called Strategies for Weight Control, and that one goes more into the physiology of body weight, things like how stress can affect appetite and cortisol levels and cause people to put more fat around the center of the body. And so it incorporates things like stress reduction exercise as well as the healthy eating and tries to focus people's thinking into the reason why they should be motivated for their own self to eat better. That's kind of the key is that I desire for each person who comes through the seminar to really know why it's for them as an individual to think about the quality of their nutrition. Are they trying to prevent cancer because that's in their genetic heritage? Are they needing just the weight control? Do they have gastrointestinal issues that they wish would go away? What is it that is their main driver for eating well? If that's not clear, you're not very directed.

Dr. Korman (22:08):
So Americans, you can tell 'em all day long, many of them to do all these things, but they don't. But that brings us to these weight loss drugs where they have gotten a lot of productivity and results, but affordability is a big issue. So who can get insurance to cover these medicines? And is this going to change or is it always going to be, unless you're a diabetic, it just doesn't get covered?

Jodi Bjurman (22:34):
No, I think there's a lot of advocacy going on right now to try to get the insurance coverage going for these weight control drugs because they are currently costing individuals like a thousand to maybe $1,300 every month if they have to pay out of pocket. So Medicare will, we'll now cover these drugs for those with diabetes. And there's a lot of work going on behind the scenes to try to get Medicare to cover them for those that don't have diabetes, that just need the weight loss for better health. So who knows that it gets into politics, it gets into availability of these drugs. There's been such a huge run on them that now the pharmacies, they have to prioritize those with diabetes, it's has gotten harder for people just to get them for weight control. They have to wait because it's just not in the pharmacy. So I think over time, our politicians and our advocates will do their work and we'll see them more available because really they're very effective for appetite control as the secondary benefit. And there is one caveat, which is that if these drugs are working for somebody to control their appetite, if they go off the drugs, the appetite comes back. So you're looking at years of staying on these drugs in order for people to be successful with their weight management.

Dr. Furnas (24:15):
What do you do with people like that? And there are also some people who can't lose weight with the skinny shots and they may be similar to other people, lose weight and regain it, and there's just sort of this overlying frustration.

Jodi Bjurman (24:31):
Well, I think again, it goes back to people tending to over restrict when they are trying to lose weight. So when I make a plan for somebody, I figure out the numbers for what would just maintain their best weight, where they feel the best. It may be a little higher than the ideal body weight. The BMI range for healthy and I develop a plan that just supports that. So if they were to come to my office for only one, maybe two visits, they would end up with a plan that would be good for them for really the rest of their life. It's not really any kind of strict weight loss plan, it's just good balanced non-excessive eating. And that's the end point that I ultimately like to teach.

Dr. Korman (25:22):
So magazines are a buzz about a new book called Dead Weight Essays on Hunger and Harm by Emily Klein. Emily writes about her own journey with an eating disorder and society's contribution by idealizing the sleek female body. When can aiming for a healthy weight overshoot into a mental illness? And are there any guardrails you can suggest?

Jodi Bjurman (25:46):
Yeah, that's an interesting question. I've had some experience with working in an eating disorder program as well. There are just classic signs when somebody's dieting attempts have gone a little bit over the edge into sort of an obsession, I would say. It's easiest to identify somebody who has that anorexic body, which is become just where there's extreme thinness, there's a constant intense fear of weight gain. There's this distorted body image where they don't see themselves as thin. They still see themselves as overweight when they have a very thin body. So that's one area. But I find that there's a lot of hidden issues with food out there in the type of eating disorder we would call avoidant restrictive food intake, where they don't really have a distorted body image or fear of weight gain, but they don't eat enough during the day. And then it might lead to overeating it at a certain time of the day or these binge eating disorders.

(27:01):
And so for our weight loss surgery patients that we talk to, there's actually quite a bit of that which develops down the road for many. And I think it's really important that we ask the right questions to see why are they regaining their weight? Can we help them not under eat so that they feel a little more satisfied and not always going into this binge, do they need psychological counseling to deal with stresses instead of going to more healthy fixes of that, instead of going to food. There is so much that can go on in the background and we just need again to ask the right question.

Dr. Furnas (27:39):
Well, Jodi, thank you so much for joining us. This has been fascinating. Is there anything else you'd like to add?

Jodi Bjurman (27:47):
Well, thank you for having me. It's been fun. I would just tell everybody to go out and seek out those healthy whole foods, get lots of plant foods in your diet, just a moderate amount of fatty animal proteins. The plants are the part of your diet that are going to really keep the body healthy and happy and give you all those antioxidants to prevent long-term disease. So I wish you all very good nutrition going forward.

Dr. Korman (28:18):
Thank you, Jodi. Join us every two weeks as we tackle topics from hair loss to hormones and pimples to wrinkles, discovering new ways to feel better about ourselves.

Dr. Furnas (28:29):
If you've enjoyed this podcast, please rate us, review us and share. Have an idea for a topic? We'd love to hear from you. Theme music by Diego Canales. Production and engineering by The Axis. See you next time.